To the best of my knowledge, all of the above answers are true and correct. If I ever have any change in my medication, I will inform the dentist at the next appointment.
The undersigned hereby authorizes Doctor to take X-rays, study models, photographs, or any other diagnostic aids deemed appropriate by Doctor to make a thorough diagnosis of the patient's dental needs. I also authorize Doctor to perform any and all forms of treatment, medication and therapy, that may be indicated. I also understand the use of anesthetic agents embodies a certain risk. I understand that responsibility for payment for Dental Services provided in this office for myself or my dependents is mine, due and payable at the time services are rendered unless financial arrangements have been made. I further understand that a finance charge will be added to any overdue balance. I also assign all insurance benefits to the Doctor.
据我所知，以上所有答案均真实正确。如果我的用药有任何变化，我会在下次预约时通知牙医。
签署人特此授权医生进行 X 光检查、研究模型、照片或任何其他医生认为合适的诊断辅助手段，以对患者的牙科需求进行全面诊断。我还授权医生执行可能需要的任何形式的治疗、药物和疗法。我还了解使用麻醉剂会带来一定的风险。我了解，我本人或我的家属在本办公室提供的牙科服务的费用由我承担，除非已做出财务安排，否则费用应在提供服务时到期并支付。我进一步了解，任何逾期余额都将增加财务费用。我还将所有保险福利转让给医生。